Insurance coverage of reconstruction

The Women’s Health and Cancer Rights Act (WHCRA) took effect in 1998. This federal law requires group health plans to pay for the following services after mastectomy:

Breast prostheses.

Breast reconstruction.

Surgery to the other breast to achieve a symmetrical appearance.

Treatment for complications from mastectomy or reconstruction.

Despite the law your initial request for reconstruction may be denied. If you belong to a managed care plan, your insurer will most likely approve your request for procedures performed in-network (with surgeons already contracted by the insurance company). You’ll have to prove why you want to go out-of-network; you may only have sufficient tissue for a GAP procedure, for example, which may not be performed in-network.

Your insurance company won’t pay for procedures it considers “medically unnecessary.” Unfortunately, some companies still consider prophylactic mastectomy to be medically unnecessary and routinely deny such requests, even for women with high hereditary risk for developing the disease. Denials may occur when a woman decides to remove both healthy breasts to reduce her breast cancer risk, or when a woman who is having unilateral mastectomy to treat breast cancer wants to have the opposite healthy breast removed also. If your request for prophylactic mastectomy and reconstruction is denied, ask your primary care physician, oncologist, and medical geneticist to write supportive letters explaining your high-risk status. As management of hereditary breast cancer risk matures, more insurers understand preventative mastectomies reduce risk as well as potential future costs of treating the disease.

To learn more about the WHCRA, contact the Department of Labor, Pensions, and Welfare Benefits Administration, 800-998-7542 or visit their website. Many states also have additional laws regarding reconstruction. Contact your state’s Department of Health or Insurance Commissioner for information.

FORCE also has sample insurance appeal letters to help people denied coverage of services needed to manage cancer risk or treat cancer.

Updated 12/27/16

FORCE:Facing Our Risk of Cancer Empowered

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